Nonsurgical Treatment of Pressure Ulcers Workup

  • Author: Christian N Kirman, MD; Chief Editor: Lars M Vistnes, MD, FRCSC, FACS   more...
 
Updated: Jan 11, 2012
 

Laboratory Studies

  • CBC with differential may show an elevated white blood cell count indicative of inflammation or invasive infection, such as osteomyelitis.
  • Erythrocyte sedimentation rate should be obtained to evaluate for inflammation and infection.
  • Nutritional parameters should be evaluated to assess adequate nutritional stores needed for adequate wound healing. Lab studies include the following:
    • Albumin level
    • Prealbumin level
    • Transferrin level
    • Serum protein level
  • When indicated by the specific clinical situation, the following laboratory studies should be obtained:
    • Urinalysis and culture in the presence of urinary incontinence
    • Stool examination for fecal white blood cells and Clostridium difficile toxin when pseudomembranous colitis may be the cause of fecal incontinence
    • Blood cultures if bacteremia or sepsis is suggested
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Procedures

  • A tissue biopsy should be performed of wounds that do not demonstrate clinical improvement despite adequate care and wounds in which tissue invasion by bacteria is suggested. This allows quantification and identification of bacterial species and their antibiotic susceptibilities. Biopsy also allows distinction between simple contamination and the more serious tissue invasion that is not revealed by the common practice of swabbing the wound surface for culture.
  • A bone biopsy should be performed for a stage IV pressure ulcer with exposed bone. If osteomyelitis is confirmed, treatment with a prolonged course of antibiotic therapy may be indicated.
  • A tissue biopsy of chronic wounds should be performed to rule out the presence of an underlying malignancy, called a Marjolin ulcer, which has been reported in chronic pressure sores as in other chronic wounds. If a chronic pressure sore has been stable for months or years but has recently deteriorated, a biopsy should be performed. Scar carcinoma is uncommon and typically occurs in wounds that have been open for many years.
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Histologic Findings

A more recently developed theory regarding wound healing is the presence of bacterial biofilms within a wound. Biofilms are structured communities of bacteria that may exist on a wound surface. A microscopic analysis of chronic wound specimens has shown the presence of densely aggregated bacterial colonies, often within their own extracellular matrix. These microscopic findings were not seen in acute wounds.[14]

Multiple in vivo studies have now shown that wound healing is delayed when these biofilms are present.[15, 16] These biofilms seem to protect the underlying bacteria and provide resistance to antibiotic treatment and the body's own immune system. Discussions among expert panels on wound healing conclude that the most effective management of biofilms within wounds is to remove the biofilm; however, methods of removal have yet to be clearly defined.[17]

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Contributor Information and Disclosures
Author

Christian N Kirman, MD  Plastic Surgeon, Department of Surgery, University of California, San Francisco, Medical Center

Christian N Kirman, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, and North Carolina Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Joseph A Molnar, MD, PhD, FACS  Director, Wound Care Center, Associate Director of Burn Unit, Associate Professor, Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine

Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Peripheral Nerve Society, Undersea and Hyperbaric Medical Society, and Wound Healing Society

Disclosure: KCI, Inc. Honoraria Speaking and teaching; Integra Life Sciences Honoraria Speaking and teaching; Clincal Cell Culture Grant/research funds Co-investigator; KCI, Inc Wake Forest University receives royalties Other

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Wayne Karl Stadelmann, MD  Stadelmann Plastic Surgery, PC

Wayne Karl Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Plastic Surgeons, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Nicolas (Nick) G Slenkovich, MD  Director, Colorado Plastic Surgery Center

Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Lars M Vistnes, MD, FRCSC, FACS  Professor of Surgery, Emeritus, Stanford University Medical Center

Lars M Vistnes, MD, FRCSC, FACS is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Don R Revis Jr, MD, to the development and writing of this article.

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Image of advanced sacral pressure ulcer shows the effects of pressure, shearing, and moisture.
Pressure ulcers of the lateral aspect of the right foot.
Heel pressure ulcer.
 
 
 
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